Can EDs have an impact on outcomes? Experts think so

Because so many use the ED as their primary access point for medical care, health plans are now targeting emergency medicine professionals as ideal providers of population-based care.

A growing number of managed care gurus are mulling over what to do about patients who suffer from chronic, debilitating diseases. According to insurance industry reports, these patients account for thousands of preventable ED visits annually. The treatment of asthmatics and diabetics with recurring problems, and patients with post-surgical complications has reportedly cost the health care system millions in less-than-fruitful treatment protocols.

Inevitably, something goes wrong with a proportion of these patients, and they end up returning to the hospital in need of acute medical care, says disease management expert Warren Todd, MBA, vice president of business development with Hastings Healthcare Group, a consulting firm in Pennington, NJ.

The protocols themselves aren't to blame, Todd says. Often, it's a case of individual physicians working at odds with each other on the patient's behalf. The emergency physician and primary care provider may not even be aware of each other during the clinical intervention despite a documented history of frequent ED encounters, says Todd, who has written a book on the subject. In effect, the patient falls through the cracks, he adds.

EDs can play a role in behavior changes

And not enough responsibility is laid on the patient's own shoulders in the treatment process. Patients aren't taking their medications properly or following their treatment regimens faithfully, Todd observes. If more patients did, there would be far fewer flare-ups and complications, and consequently fewer unplanned ED visits. He concludes: "In trying to manage the patient's disease, we've mistakenly omitted the importance of working together as clinicians in managing the patient's attitudes toward the [treatment] process."

Authorities now believe that emergency physicians can play a role in achieving successful, predictable outcomes for patients with long-term diseases and post-surgical complications. The key is to manage these patients at the point in which they enter the acute-care system, Todd observes.

"Emergency providers can have a valuable impact because of the point in time in which they see these patients. During these encounters, patients are the most vulnerable and receptive to intervention," he says. At these times, emergency physicians are in the best position to teach patients new behaviors about handling their disorders. That type of intervention, experts say, can start a process that can be reinforced later in the physician's office or a sub-acute setting.

Several emergency physicians are beginning to agree with this view. "EDs are the point at which all roads meet in the acute-care process. I see emergency medicine as a true integrator of medical care," says Toni A. Mitchell, MD, vice chief of emergency services at 900-bed Tampa (FL) General Hospital. In addition, other experts cite the round-the-clock availability of emergency services and the well-trained, diversified acute-care staff found in EDs for making them ideal places for changing a broad range of patient behaviors.1

Mitchell and her colleagues recently launched a dedicated patient management program at Tampa General that includes the emergency services personnel. The program is designed to closely monitor high-risk post-surgical cardiac and joint replacement surgery patients in separate, integrated case management programs that employ approved clinical guidelines and internally developed best-practices techniques.

The patient categories were chosen, Mitchell says, based on the high volume of cardiac and joint replacement procedures performed at the hospital and the potential for costly patient recidivism in these two patient populations. The goal, according to Mitchell, is to improve long-range outcomes and reduce cost, including repeat ED visits.

Hospitals lack an integrated experience

But for hospitals in general, carving out specific patient groups and targeting them with formalized treatment protocols is a relatively new phenomenon. Although population-based care systems have been widely discussed for years, few providers have actually implemented successful programs, Mitchell says. "It's difficult to find many hospitals doing this yet in any serious way," Todd notes.

By far, primary-care physicians and specialists have been more familiar with the idea. But overall, it hasn't quite caught on among most providers, says Joseph Anderson, president and chief executive officer of Schaller Anderson, a Phoenix, AZ-based company that manages health maintenance organizations (HMOs) nationally. Here are some reasons why:

Providers have successfully integrated many of their clinical programs. But they've had less success in creating an integrated clinical infrastructure that can effectively track high-risk patients through the acute-care setting to final discharge and post-institutional care, says Mitchell. Many are only beginning to do so.

Unless they belong to large, fully integrated delivery systems, hospitals and physician groups lack the sophisticated information systems to extensively track and study the effectiveness of population-based care programs, Todd says. Providers have only recently learned how to use the data stored in computers for long-range purposes. But, in most cases, the data remain fragmented and not available to all providers in contact with the same patients.

Finally, there is no proof that disease-management strategies actually work. "There isn't yet enough evidence or an established track record to support claims for population-based disease management," says Carolyn M. Clancy, MD, director of the Center for Outcomes and Effectiveness Research at the federally-funded Agency for Health Care Policy and Research in Rockville, MD.

Providers may be attracted to population-based care by other concerns as well. Capitation is raising questions about what to do about high-risk patients, says Anderson. As providers assume more financial risk, they face increased pressure to micromanage the quality and resources used to maximize positive outcomes. "This is especially important when managing the care of the 5-20% of the [patients] that consume 70-80% of health care resources," says Raul A Trillo, Jr., MD, a former Ernst & Young consultant now with Ohmeda PPD, a pharmaceutical firm in Liberty Corner, NJ.

A lot is at stake for providers

In addition, accreditation organizations such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) are demanding more and better results from providers. JCAHO, which evaluates health care facilities on their performance, recently revised its hospital reporting criteria, effectively creating tougher standards and oversight for hospitals.

But for emergency physicians, population-based systems of care pose unique circumstances. "Hospitals are caught up in a schizophrenic scenario," Todd observes. "On one hand, they need to fill beds and maintain utilization to achieve a decent revenue stream. On the other, managed care is, by default, telling them to cut back on volume." And very few EDs are currently assuming risk. Most are still paid under a discounted fee-for service arrangement. (For a wider discussion on capitation in emergency medicine, see the cover story in this issue, p. 35.)

So there are few incentives for population-based care management. Also, patient visits tend to be unplanned and the patients themselves are varied in their presenting complaints and final diagnoses. They're difficult to follow beyond the ED encounter, and they often originate from places well outside the community, says Clancy.

So, is emergency medicine adaptable to population-based care principles? "Yes, if the ED becomes part of an integrated system of care," says Scott Wolf, DO, director of ambulatory medicine at Hartford (CT) Hospital. In 1996, the 819-bed inner-city provider opened a dedicated outpatient asthma management program for high-risk patients that integrates the hospital's primary-care physicians practices, its inpatient referral system, and its emergency medical services.

Using asthma protocols established by the National Institutes of Health, the hospital enrolls patients from the three referral sources into a high-impact management program that stresses prevention, maintenance, self-care, and lifestyle changes. In the program's first year, ED utilization for patients who had visited the department prior to joining the program dropped by 47%, according to Wolf. Inpatient admissions for the same high-risk group fell by 71%. The hospital is planning a similar program for at-risk diabetics.

Several elements must be in place

For emergency providers, becoming part of a population management team is no easy task. What follows is a series of suggestions cited by experts to help providers plug into a hospital-wide effort:

Staffing. The unpredictable nature of emergencies requires a well-trained workforce prepared to make rapid, accurate assessments and therapeutic decisions. Departments also need to have sufficient capacity to manage many patients concurrently.1 "Emergency physicians must be able to manage transitions to the next phase of care," Clancy notes in a published article.

Teamwork. This means the ability to make collaborative, intradepartmental decisions and to coordinate reductions in utilization and cost while continuing to maintain quality standards system-wide, Trillo notes. "Everyone has to be operating on the same page," observes Mitchell.

Segmentation. The more defined the patient population, the more closely the service can be targeted to the at-risk group, Trillo says. Patient groups can be divided into various groupings: uninsured pediatric cases, Medicaid-only patients, juvenile diabetics, or cardiac patients over the age of 55. But, each link of the patient management chain must adhere to the same set of practices.

Experience. One of the reasons EDs may be well-equipped for a role in population-based care is high-acuity patient volume. "These programs work best where high-acuity experience is strong," says Anderson of Schaller Anderson. Hospitals that have high experience levels with particular chronic disease such as asthma or with the public health problems of the indigent and uninsured are in a better position to contribute to effective population-based care systems, Anderson adds.

Integrated information systems. Providers need to share clinical data system-wide, says Todd. But they also need to agree on certain criteria for evaluating the data and coordinating the management program to fit the specific, limited needs of the at-risk population, says Clancy. That may be difficult to achieve. Unfortunately, "we haven't figured out well enough how to [use the data to] study the impact of the delivery system on patients and their outcomes," Clancy says. The process begins with meetings among department heads and clinicians. Although population-based care is a beginning, there is still a long way to go, Clancy concludes.


    1. Clancy CM, Eisenberg JM. Emergency medicine in population-based systems of care. Ann Emerg Med 1997; 30:800-803.